65 year old male with pain abdomen since 5 days

Medical case disscussion 

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        CASE DISCUSSION

Patient came to OPD with chief complaints of pain abdomen since 5 days

HOPI :  

Patient was apparently asymptomatic 5 days back then he developed pain  abdomen, insidious in onset, gradually progressive dragging type,aggravated on doing work ,after consumption of alcohol ,not associated with nausea,vomitings

No h/o fever,cold,cough

No h/o constipation ,diarrhea

No h/o palpitations,edema, PND, ORTHOPNEA.

Past history 

N/k/c/o HTN, Asthma, epilepsy,TB , CAD,CVA

No h/o surgeries in the past 

No H/O blood transfusion 

No h/o radiation exposure

Personal history: patient is farmer by occupation 

Diet mixed

Appetite decreased since 5 days 

Sleep adequate

Bowel regular 

Micturition not normal 

Burning micturition

SLEEP ADEQUATE.

Addictions regularly consumes alcohol about 90 ml/day 

Since 30 years 

General physical examination

Pt is conscious coherent cooperative well oriented to time place person

Moderately built and nourished

Vitals

Bp : 130/80 mm Hg 

Pr : 69 bpm

Spo2 98 on RA 

Temp: 98.3 F

Grbs 197 mg/dl

cyanosis, clubbing, lymphadenopathy,edema

Icterus present 

Pallor present 

Systemic examination : 

Cvs  : s1 ,s2 heard

CNS  : no focal neurological deficits noted

Rs  : BAE + , NVBS 

P/A : 

Inspection : abdomen flat 

No scars,sinuses,hernial orifices, pulses,masses,

All quadrants are moving equally with respiration

Grey turner sign ( bluish discolouration of flanks) and Cullens sign( bluish discolouration of periumbilical area ) are negative [ These are +ve in patients with severe pancreatitis with Haemorrhage ]

On palpation: 

All inspectory findings are confirmed 

Abdomen soft 

Tenderness in epigastric and both hypochondriac regions

No local rise of temperature

Guarding+ 

Rigidity absent

Percussion :

Liver span: normal

Auscultation: 

Sluggish bowel sounds are heard.

Provisional diagnosis : acute on chronic pancreatitis

Investigations done on 27/11/23 

USG ABDOMEN AND PELVIS 

x ray erect abdomen 

Chest x ray : 

Investigations done on 28/11/23 

Final diagnosis : 

Acute on chronic pancreatitis

Treatment:

IVF ns @ 100 ML/hr 

Inj ceftriaxone 2 g /IV / BD 

INJ METROGYL 500 mg IV /TID

Inj thiamine 200 mg in 100 ML NS IV/tid 

Inj Tramadol 100 mg in 100 ML NS IV/BD 

INJ PAN 40 Mg IV /OD 

INJ ZOFER 4 Mg IV /BD